Consumers tackle health-care priorities

Games, discussion groups put people in role of choosing, excluding benefits

This update corrects the name of the nonprofit run by Marge Ginsburg. It is the Center for Healthcare Decisions.

SAN FRANCISCO (MarketWatch) -- What is health care, and how much of it should be covered by communal dollars in a private or public health plan?

Contrary to the shouting matches that broke out in some town-hall meetings earlier this month, Americans tend to be circumspect when considering what health insurance should cover in a basic plan, especially when they're engaged in a meaningful discussion of the trade-offs, health-policy experts say.

Most people don't get the opportunity to confront the difficult compromises inherent in choosing health benefits for more than just themselves and their families.

As U.S. lawmakers try to agree on how to overhaul the health-care system, several states, employers and a nonprofit group have been challenging everyday citizens to find common ground in the struggle to control rising health costs. They're engaging consumers through surveys, game simulations and dialogue to flesh out which coverage items they perceive as most critical to their needs and the needs of others. The feedback is used to inform policy and sometimes to change benefits design.

This approach invites Americans from all walks of life to determine what goods and services are essential for coverage, and at what level of personal financial responsibility, given limited funding. The catch is that the more that's covered, the higher the cost of having that coverage for everyone, requiring people to make some exclusions.

A tool called Choosing Healthplans All Together, or CHAT, created 10 years ago by researchers from the University of Michigan and the National Institutes of Health, is gaining traction as states grapple with how to balance a minimum coverage standard with people's ability to pay for it. North Dakota is launching a CHAT project through its state insurance department. Oklahoma's insurance department is further along, applying its CHAT results to policy changes aimed at getting more of the state's young people insured.

In the first round of the game, individuals make choices by themselves for themselves or their families only. In the second round they do the same but in groups of three. The third round forces them to choose coverage for their community by engaging in concessions and benefit-trading.

The fourth round is optional, but asks individuals to go back and choose their own benefits again to see how they changed their minds over the course of the exercise, which typically lasts one to two hours, said Susan Dorr Goold, professor of internal medicine and director of the bioethics program at the University of Michigan Medical School in Ann Arbor.

Giving in order to get

If lawmakers end up considering a minimum benefits package as part of heath reform, as both the House tri-committee and Senate HELP committee bills call for so far, results from CHAT and other tools may be a guide.

"The exercise itself I think appeals to people across the political spectrum in part because there is this issue of choice and control as well as shared concern for community well-being," Goold said. "Those ideas often transcend political...preconceived opinions."

"Engaging the public in those discussions maybe could overcome some of the perceived reluctance of the public to talk about, dare I say, rationing," she said. "Frankly, when they get talking about it, they recognize you can't have it all."

About 850 people have participated in CHAT in Oklahoma over two years as part of a broader statewide health-reform effort, Insurance Commissioner Kim Holland said. Nearly 20% of Oklahoma's 3.5 million people are uninsured, about half of whom are young adults under age 35.

"What our citizens really care about and believe insurance is fundamentally there to do is to make sure if you have a catastrophic illness you're covered, including a transplant if a doctor indicates you could benefit," Holland said.

Other CHAT results showed Oklahomans support comprehensive coverage for mental-health services, she said.

"They feel strongly about preventive services, but they're more than willing to give up some nice things we customarily cover under a health plan like chiropractic care or what we might consider lifestyle enhancements like Viagra or in vitro fertilization" in order to extend basic coverage to everyone.

"We found our participants to be quite thoughtful and reasonable about their approach, recognizing there's trade-offs in all these decisions," Holland said.

Feedback from the experiment led to a change in state law that will allow health insurers to bypass 15 state mandates such as providing wigs for cancer patients in order to make coverage more affordable for people under 40, she said.

Ranking priorities

Marge Ginsburg, executive director of the nonprofit Center for Healthcare Decisions in Sacramento, Calif., estimates she's conducted nearly 300 CHAT sessions in the last seven years among 40 public- and private-sector employers.

"We all know if people had their druthers everything would be on the menu," she said. "But as the reality of finite resources starts to come to folks, they start to say 'Let's look at this.'"

As medical technology advances and life expectancy climbs, demands on health insurance have grown from covering only catastrophic costs to including an array of preventive-care and quality-of-life services as well.

"A whole lot of what we do in health care really needs to be viewed through the telescope of a social decision," Ginsburg said. "We didn't used to have to do that. We didn't have chronic illness, so we didn't have this quandary of having more that we could do than we could pay for."

When people get past their own immediate self-interest and have to make tough sacrifices for the greater good, they typically rise to the occasion, Ginsburg said.

"When people are in that role, they make perfectly rational, common-sense decisions," she said. "There's always a subset of the group that says 'Under no conditions should cost be taken into account,' but that's a minority view. Most of them say, 'Yeah, it has to.'"

Earlier this year, Consumers for Healthcare Choices sponsored a telephone survey of 1,019 Californians, asking them to assign coverage priorities using medical vignettes such as a young man's desire for laser eye surgery so he can play sports without wearing glasses or a middle-aged woman's curable skin cancer. The group then followed up with 15 two-hour group discussions to learn more about why people responded the way they did.

Some scenarios bring widespread agreement. California consumers rated problems that are likely to lead to illness, disease or death if not prevented or treated as a high-priority situation for coverage.

They also were sympathetic to the need for insuring against problems that interfere with daily functioning essential for working, self-care and family care. Issues that may result in much higher societal costs if not treated early also were deemed high priority, according to Consumers for Healthcare Choices.

In the middle, drawing some support for coverage, were problems that cause physical discomfort but don't interfere with major activities of living and those that bring personal distress to the individual.

On the bottom rung of the priority ladder were problems that were unsightly but not physically harmful, those that prevent individuals from pursuing recreational activities, treatments patients request for convenience or to feel reassured and problems that would resolve over time without treatment.

"Most people are most comfortable with the idea of finding a compromise rather than just saying no," Ginsburg said. "They really do believe that insurance can't pay for everything. I think we have come to that conclusion as a society."

Little support for high deductibles

When asked which statements were closest to their views on how to help control the rising cost of health care, 36% said patients themselves should pay at least half the cost of treatment for lower-priority medical problems. Thirty percent said patients should pay a somewhat higher co-payment than they do for other services.

Only 14% said patients should be on the hook for the full cost if they want service for lower-priority medical problems, and that health insurance shouldn't cover any of the cost in these circumstances. On the opposite extreme, 20% said other steps should be taken to control costs, but that even lower-priority medical problems should be covered by health insurance.

A big sticking point appears to be high-deductible plans, which tend to offer lower premiums in exchange for higher upfront costs. Those are often highly unpopular among discussion participants, Ginsburg said.

"They're more than willing to pay what they feel is reasonable, but they would rather change the way certain things are done in the benefits package than be all about high cost-sharing. If their basic plan is going to be the $5,000 deductible, forget it," she said.

"It does nobody any good to have a rich and comprehensive benefits package in name only when in fact you can't get in the door," Ginsburg said. "That's a really big message."

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